Management of frailty in the community setting
Authors: Jean Woo
Journal: The Lancet Healthy Longevity (2022)

Research on the topic of healthy longevity tends to be dominated by morbidity and mortality of non-communicable diseases and their prevention. By contrast, there has been an exponential increase in the number of articles in gerontological and geriatrics journals devoted to the topic of age-related changes and the consequences of these changes to public health and use of health services. The manifestation of such changes includes frailty (both physical and cognitive), sarcopenia, and, in recent years, the concept of intrinsic capacity. WHO is promoting the Decade of Healthy Ageing from 2020, in which maintenance of function rather than absence of disease is the overriding goal, and intrinsic capacity is a measure of healthy ageing.1WHODecade of healthy ageing: baseline report—summary.https://www.who.int/publications/i/item/9789240023307Date: April 30, 2021Date accessed: May 19, 2022Google Scholar This topic has yet to be given the importance it deserves outside of the gerontological and geriatrics fields. Age-related physiological changes manifesting as geriatric syndromes have been characterised in similar ways to diseases, with regards to diagnosis, screening, pathophysiology, prevention, and treatment. In recent years, interventions in the community have been studied using randomised controlled trials.2Ruiz JG Dent E Morley JE et al.Screening for and managing the person with frailty in primary care: ICFSR consensus guidelines.J Nutr Health Aging. 2020; 24: 920-927Crossref PubMed Google Scholar, 3Dent E Martin FC Bergman H Woo J Romero-Ortuno R Walston JD Management of frailty: opportunities, challenges, and future directions.Lancet. 2019; 394: 1376-1386Summary Full Text Full Text PDF PubMed Scopus (346) Google Scholar However, few randomised controlled trials have explored the long-lasting effects beyond the period of intervention. Such trials are difficult to carry out, and yet would be important for adoption into routine health and social care systems. In The Lancet Healthy Longevity, Ruth Teh and colleagues report on such a randomised controlled trial from New Zealand.4Teh R Barnett D Edlin R et al.Effectiveness of a complex intervention of group-based nutrition and physical activity to prevent frailty in pre-frail older adults (SUPER): a randomised controlled trial.Lancet Healthy Longev. 2022; 3: e521-e532Summary Full Text Full Text PDF Scopus (1) Google Scholar The study examines the effectiveness of a nutrition intervention, an exercise intervention, and an intervention combining nutrition and exercise, in relation to a social activities programme, in a real-world situation. The study also addresses the issue of adherence and sustainability through the transition to peer-led sessions.The study found improvements in frailty status in the nutrition, exercise, and combination groups, compared with the control group not participating in either activity, over 12 months. Improvement in the group participating in the combined intervention was not greater than that in the groups participating in the nutrition or exercise interventions. This finding is in contrast to some other randomised controlled trials in which exercise interventions, using objective physical measurements such as physical performance measures, were markedly more effective than nutrition interventions. It could be argued that using the frailty classification as an outcome might be more meaningful as a patient-related outcome measure than only physical performance measures. Because nutritional status is an important risk factor for frailty, it would be of interest to have more detailed information relating to the baseline nutritional status in the trial sample, in terms of protein and vitamin D intake in addition to total calorie intake, and whether this changed as a result of the cooking classes in the nutrition intervention. Standardised nutrition education usually addresses the general adult population, with an emphasis on chronic diseases rather than on targeting geriatric syndromes specifically by emphasising brain, muscle, and bone health. It is possible that the benefit of cooking classes might not be related to improved nutritional status or nutritional knowledge, but exerts its effects through increased physical activity and social interaction, or by targeting social frailty.5Pek K Chew J Lim JP et al.Social frailty is independently associated with mood, nutrition, physical performance, and physical activity: insights from a theory-guided approach.Int J Environ Res Public Health. 2020; 174239Crossref PubMed Scopus (26) Google Scholar The exercise intervention that was used in the trial is the Otago Exercise Programme for falls. Although falls are a downstream consequence of frailty, it is uncertain how effective this programme would be at targeting frailty, compared with exercise programmes such as the Vivifrail programme, which can be adapted to participants with different levels of frailty.6Izquierdo M Merchant RA Morley JE et al.International exercise recommendations in older adults (ICFSR): expert consensus guidelines.J Nutr Health Aging. 2021; 25: 824-853Crossref PubMed Scopus (105) Google Scholar By 12 months after the intervention, all improvements had disappeared in the three intervention groups. However, deterioration in frailty scores was observed in the social group by 24 months, which suggests that there is a residual effect in terms of slower deterioration in the three intervention groups. Teh and colleagues attempted to address the issue of sustainability by introducing peer-led groups in the last weeks of the intervention. This is a good strategy, but the results, in terms of the proportion of participants who continued on to this format, were variable. It is also uncertain how the COVID-19 pandemic affected participants, even though there was no interruption in data collection. It might have been difficult for participants to make use of the knowledge and practice gained from the intervention groups as a result of pandemic measures.This study shows which programmes might be incorporated into existing health systems for frailty intervention. Ideally, a long-lasting effect should be possible with behavioural change, supported by community peer-led programmes. Insights from behavioural scientists would be useful to promote behavioural change, but the strongest motivation for older adults would probably be that they feel better after participation, accompanied by gaining an understanding of how ageing processes might be slowed down as a result of the interventions.7Yu R So MC Tong C Ho F Woo J Older adults' perspective towards participation in a multicomponent frailty prevention program: a qualitative study.J Nutr Health Aging. 2020; 24: 758-764Crossref PubMed Scopus (4) Google Scholar Research on the topic of healthy longevity tends to be dominated by morbidity and mortality of non-communicable diseases and their prevention. By contrast, there has been an exponential increase in the number of articles in gerontological and geriatrics journals devoted to the topic of age-related changes and the consequences of these changes to public health and use of health services. The manifestation of such changes includes frailty (both physical and cognitive), sarcopenia, and, in recent years, the concept of intrinsic capacity. WHO is promoting the Decade of Healthy Ageing from 2020, in which maintenance of function rather than absence of disease is the overriding goal, and intrinsic capacity is a measure of healthy ageing.1WHODecade of healthy ageing: baseline report—summary.https://www.who.int/publications/i/item/9789240023307Date: April 30, 2021Date accessed: May 19, 2022Google Scholar This topic has yet to be given the importance it deserves outside of the gerontological and geriatrics fields. Age-related physiological changes manifesting as geriatric syndromes have been characterised in similar ways to diseases, with regards to diagnosis, screening, pathophysiology, prevention, and treatment. In recent years, interventions in the community have been studied using randomised controlled trials.2Ruiz JG Dent E Morley JE et al.Screening for and managing the person with frailty in primary care: ICFSR consensus guidelines.J Nutr Health Aging. 2020; 24: 920-927Crossref PubMed Google Scholar, 3Dent E Martin FC Bergman H Woo J Romero-Ortuno R Walston JD Management of frailty: opportunities, challenges, and future directions.Lancet. 2019; 394: 1376-1386Summary Full Text Full Text PDF PubMed Scopus (346) Google Scholar However, few randomised controlled trials have explored the long-lasting effects beyond the period of intervention. Such trials are difficult to carry out, and yet would be important for adoption into routine health and social care systems. In The Lancet Healthy Longevity, Ruth Teh and colleagues report on such a randomised controlled trial from New Zealand.4Teh R Barnett D Edlin R et al.Effectiveness of a complex intervention of group-based nutrition and physical activity to prevent frailty in pre-frail older adults (SUPER): a randomised controlled trial.Lancet Healthy Longev. 2022; 3: e521-e532Summary Full Text Full Text PDF Scopus (1) Google Scholar The study examines the effectiveness of a nutrition intervention, an exercise intervention, and an intervention combining nutrition and exercise, in relation to a social activities programme, in a real-world situation. The study also addresses the issue of adherence and sustainability through the transition to peer-led sessions. The study found improvements in frailty status in the nutrition, exercise, and combination groups, compared with the control group not participating in either activity, over 12 months. Improvement in the group participating in the combined intervention was not greater than that in the groups participating in the nutrition or exercise interventions. This finding is in contrast to some other randomised controlled trials in which exercise interventions, using objective physical measurements such as physical performance measures, were markedly more effective than nutrition interventions. It could be argued that using the frailty classification as an outcome might be more meaningful as a patient-related outcome measure than only physical performance measures. Because nutritional status is an important risk factor for frailty, it would be of interest to have more detailed information relating to the baseline nutritional status in the trial sample, in terms of protein and vitamin D intake in addition to total calorie intake, and whether this changed as a result of the cooking classes in the nutrition intervention. Standardised nutrition education usually addresses the general adult population, with an emphasis on chronic diseases rather than on targeting geriatric syndromes specifically by emphasising brain, muscle, and bone health. It is possible that the benefit of cooking classes might not be related to improved nutritional status or nutritional knowledge, but exerts its effects through increased physical activity and social interaction, or by targeting social frailty.5Pek K Chew J Lim JP et al.Social frailty is independently associated with mood, nutrition, physical performance, and physical activity: insights from a theory-guided approach.Int J Environ Res Public Health. 2020; 174239Crossref PubMed Scopus (26) Google Scholar The exercise intervention that was used in the trial is the Otago Exercise Programme for falls. Although falls are a downstream consequence of frailty, it is uncertain how effective this programme would be at targeting frailty, compared with exercise programmes such as the Vivifrail programme, which can be adapted to participants with different levels of frailty.6Izquierdo M Merchant RA Morley JE et al.International exercise recommendations in older adults (ICFSR): expert consensus guidelines.J Nutr Health Aging. 2021; 25: 824-853Crossref PubMed Scopus (105) Google Scholar By 12 months after the intervention, all improvements had disappeared in the three intervention groups. However, deterioration in frailty scores was observed in the social group by 24 months, which suggests that there is a residual effect in terms of slower deterioration in the three intervention groups. Teh and colleagues attempted to address the issue of sustainability by introducing peer-led groups in the last weeks of the intervention. This is a good strategy, but the results, in terms of the proportion of participants who continued on to this format, were variable. It is also uncertain how the COVID-19 pandemic affected participants, even though there was no interruption in data collection. It might have been difficult for participants to make use of the knowledge and practice gained from the intervention groups as a result of pandemic measures. This study shows which programmes might be incorporated into existing health systems for frailty intervention. Ideally, a long-lasting effect should be possible with behavioural change, supported by community peer-led programmes. Insights from behavioural scientists would be useful to promote behavioural change, but the strongest motivation for older adults would probably be that they feel better after participation, accompanied by gaining an understanding of how ageing processes might be slowed down as a result of the interventions.7Yu R So MC Tong C Ho F Woo J Older adults' perspective towards participation in a multicomponent frailty prevention program: a qualitative study.J Nutr Health Aging. 2020; 24: 758-764Crossref PubMed Scopus (4) Google Scholar I declare no competing interests. Effectiveness of a complex intervention of group-based nutrition and physical activity to prevent frailty in pre-frail older adults (SUPER): a randomised controlled trialThe study did not find that the combined SC and SAYGO programme was effective in reducing frailty in pre-frail older adults. Although some short-term benefits were observed in each individual programme, there was no clear evidence of long-term impact. Further research is needed to evaluate combinations of group-based programmes for community-dwelling older adults to optimise their physical function. Full-Text PDF Open Access